Provider Demographics
NPI:1326123951
Name:GRIMM, ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:GRIMM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 N LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-2313
Mailing Address - Country:US
Mailing Address - Phone:323-687-0096
Mailing Address - Fax:
Practice Address - Street 1:1144 N ORANGE GROVE AVE APT 7
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5489
Practice Address - Country:US
Practice Address - Phone:323-687-0096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO434682085R0202X
CAA760252085R0202X
NY3015192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A760250OtherBLUE SHIELD
CO94181888Medicaid
00A760250OtherBLUE SHIELD
CAAX538ZMedicare PIN
I38799Medicare UPIN
802709Medicare ID - Type Unspecified